Comprehensive Psychiatry 94 (2019) 152116

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Comprehensive Psychiatry

journal homepage: www.elsevier.com/locate/comppsych

The relationship between obsessive-compulsive disorder and anxiety

disorders: A question of diagnostic boundaries or simply severity
of symptoms?
Paula Vigne a, Bruno F.T. Simões b, Gabriela B. de Menezes a,c, Pedro P. Fortes a, Rafaela V. Dias a,
Luana D. Laurito a, Carla P. Loureiro a, Maria Eduarda Moreira-de-Oliveira a,c, Lucy Albertella d, Rico S.C. Lee d,
Ulrich Stangier e, Leonardo F. Fontenelle a,c,d,⁎
a
Institute of Psychiatry, Federal University of Rio de Janeiro, Brazil
b
Department of Quantitative Methods, Federal University of the State of Rio de Janeiro (UNIRIO), Brazil
c
D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
d
Turner Institute for Brain and Mental Health, Monash University, Victoria, Australia
e
Department of Psychology, University of Frankfurt, Germany

a r t i c l e i n f o a b s t r a c t

Available online xxxx Background: A growing number of studies are questioning the validity of current DSM diagnoses, either as “dis-
crete” or distinct mental disorders and/or as phenotypically homogeneous syndromes. In this study, we investi-
gated how symptom domains in patients with a main diagnosis of obsessive-compulsive disorder (OCD), panic
Keywords: disorder (PD) and social anxiety disorder (SAD) coaggregate. We predicted that symptom domains would be un-
Severity of symptoms related to DSM diagnostic categories and less likely to cluster with each other as severity increases.
General neurotic syndrome Methods: One-hundred eight treatment seeking patients with a main diagnosis of OCD, SAD or PD were assessed
Neuroticism with the Dimensional Obsessive-Compulsive Scale (DOCS), the Social Phobia Inventory (SPIN), the Panic and Ag-
Anxiety sensitivity
oraphobia Scale (PAS), the Anxiety Sensitivity Index-Revised (ASI-R), and the Beck Depression and Anxiety In-
Obsessive–compulsive disorder
ventories (BDI and BAI, respectively). Subscores generated by each scale (herein termed “symptom domains”)
Social anxiety disorder
Panic disorder were used to categorize individuals into mild, moderate and severe subgroups through K-means clusterization
and subsequently analysed by means of multiple correspondence analysis.
Results: Broadly, we observed that symptom domains of OCD, SAD or PD tend to cluster on the basis of their se-
verities rather than their DSM diagnostic labels. In particular, symptom domains and disorders were grouped into
(1) a single mild “neurotic” syndrome characterized by multiple, closely related and co-occurring mild symptom
domains; (2) two moderate (complicated and uncomplicated) “neurotic” syndromes (the former associated
with panic disorder); and (3) severe but dispersed “neurotic” symptom domains.
Conclusion: Our findings suggest that symptoms domains of treatment seeking patients with OCD and anxiety
disorders tend to be better conceptualized in terms of severity rather than rigid diagnostic boundaries.
© 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Despite being listed in different chapters of DSM5 [i.e. obsessive-
compulsive and related disorders (OCRDs) and anxiety disorders],
obsessive-compulsive disorder (OCD), social anxiety disorder (SAD)
and panic disorder (PD) are closely related to each other, as shown by
shared symptoms (e.g. prominent fears and avoidant behaviors) [1],
co-occurrence [2], common genetic factors [3,4], increased family ac-
commodation [5], and treatment response to serotonin reuptake
⁎ Corresponding author at: Turner Institute for Brain and Mental Health, MONASH
University, 770 Blackburn Road, Clayton, VIC 3168, Australia.
E-mail address: leo.fontenelle@monash.edu (L.F. Fontenelle).
inhibitors [6] and exposure-based therapies [7]. Also, the relationship
between OCD, SAD and PD remain tacitly recognized in many diagnostic
schemes. For instance, OCD and anxiety disorders were historically
grouped under “neurotic” conditions by early theorists or simply as
“anxiety disorders” across several DSM versions [8,9]. In DSM-5, despite
their “splitting,” the OCRDs chapter remains straight after anxiety disor-
ders as a recognition of their close relationship [1]. Lastly, in more recent
diagnostic models, such as the Hierarchical Taxonomy Of Psychopathol-
ogy (HiTOP) [10], OCD and anxiety disorders are described as belonging
to the same fear subfactor.
Although OCD and anxiety disorders show many commonalities, the
optimal way to conceptualize the association between these conditions
is not completely clear (see Fig. 1). For instance, in DSM-5, both OCD and

https://doi.org/10.1016/j.comppsych.2019.152116
0010-440X/© 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 P. Vigne et al. / Comprehensive Psychiatry 94 (2019) 152116

Fig. 1. Illustration of the models investigated in the present study. Model 1A depict current (DSM5) categorical conceptualization of OCD and anxiety disorders, which posits these
disorders as well defined entities containing their characteristic symptoms. In this model, symptoms from different disorders may co-occur, but remain characteristic of one specific
disorder. In the model 1B (“dimensional symptoms model”), symptoms from different disorders are intertwined with each other and can be shared by more than one single disorder.
Finally, In the model 1C (“dimensional severity model”), OCD and anxiety disorders lie within the same spectrum of severity. OCD = obsessive-compulsive disorder; OCD1, OCD2,
OCD3, and OCD4 = hypothetical OCD symptom domains; SAD = social anxiety disorder; SAD1, SAD2, SAD3, and SAD4 = hypothetical SAD symptom domains; PD = panic disorder;
PD1, PD2, PD3 and PD4 = hypothetical PD symptoms domains.

anxiety disorders are considered as categories, i.e. discrete conditions
with well-defined boundaries that contain defining symptoms almost
unique to each diagnosis (Model 1a). In contrast, an alternative ap-
proach (a “dimensional symptoms model”) acknowledges the potential
co-existence of symptoms that are unique to each disorder (like DSM5)
along with other shared symptoms (Model 1b). For instance, whereas
some OCD phenotypes (i.e. “shameful” symptoms) seem to result in
greater social anxiety [11], the performance-only subtype of SAD has
been more clearly related to panic attacks than the generalized pheno-
type [12], and certain cognitions (“fear of dying”) seem to be shared by
PD and OCD [13]. Finally, in the “dimensional severity model”, OCD and
anxiety disorders can be considered different expressions of a common
diathesis, which could then be represented along a continuum of sever-
ity (Model 1c).
In this study, to determine how the relationship between OCD, SAD
and PD is best conceptualized (i.e. categorically or dimensionally), we
investigated how diagnostic categories and their corresponding symp-
toms coaggregate in a transdiagnostic treatment seeking sample. To
do so, subjects were assessed with the Mini International Neuropsychi-
atric Interview (MINI) to provide diagnostic categories and a series of di-
mensional scales that were decomposed into their subscores to provide
information about the presence and severity of different OCD, SAD, and
PD symptom domains. Based on the literature supporting increased co-
morbidity between OCD and anxiety disorders [2], and studies showing
that mental disorders (including OCD [14–16] and panic disorder [17–
19]) may have a history of non-specific psychopathology or “pluripo-
tent” [20] yet milder common prodromal symptoms, we predicted
that the investigated symptom domains [1] do not map into their corre-
sponding OCD, SAD, and PD diagnostic categories and [2] are less likely
to cluster together as they increase in severity.
2. Material and methods
2.1. Participants
The sample for this study included 108 individuals who were diag-
nosed with DSM-IV OCD (n = 38); SAD (n = 34) or PD (n = 36)
using the Mini International Neuropsychiatric Interview (MINI) [21]. In-
clusion criteria were: (i) a primary diagnosis of OCD, SAD or PD; (ii) age
between 18 and 70 years; and (iii) being able to read and fill out forms.
The exclusion criteria comprised severe mental disorders that could
compromise the interpretation of the responses (e.g. mental retarda-
tion, current manic or psychotic episodes, or dementia) or severe per-
sonality disorders (according to the attending physician). Participants
were consecutively recruited from patients who sought treatment in
the Obsessive, Compulsive, and Anxiety Research Program and in the
Laboratory of Panic and Respiration at the Institute of Psychiatry of Fed-
eral University of Rio de Janeiro. If eligible for the present study, the par-
ticipants were informed about the study goals and invited to participate.
After having signed the consent form, they completed self-report scales
in the presence of a psychologist. The research ethics committee of the
Institute of Psychiatry of Federal University of Rio de Janeiro has ap-
proved this research protocol (CAAE 50308015.1.0000.5263).
 P. Vigne et al. / Comprehensive Psychiatry 94 (2019) 152116
2.2. Severity of symptoms
In order to measure the severity of obsessive-compulsive, social anx-
iety, and panic symptoms, we employed, respectively, the Brazilian Por-
tuguese versions of the Dimensional Obsessive-Compulsive Scale
(DOCS), a 20-item self-report scale that provides global as well as spe-
cific scores on concerns about germs and contamination, concerns
about being responsible for harm, injury, or bad luck; unacceptable
(taboo) thoughts, and concerns about symmetry, completeness, and
the need for things to be “just right” [22]; the Social Phobia Inventory
(SPIN), a 17-item self-report instrument that, besides providing a global
score, generates subscores on fear, avoidance, and physical discomfort
[23]; and the Panic and Agoraphobia Scale (PAS), a 13- item self-
report scale that results in total, panic attacks, agoraphobia/avoidant be-
haviors, anticipatory anxiety, and disability and worries about health
scores [24,25].
To assess anxiety sensitivity, the Brazilian Portuguese translation of
the Anxiety Sensitivity Index-36 (ASI-36) was employed. The ASI-36 is
a 36-item self-report instrument that evaluates fear of anxiety-related
cognitions and sensations, and behaviors that are based on beliefs
about their harmful consequences, and generates global scores and
subscores regarding fears of cardiovascular, respiratory, gastrointestinal
and neurological symptoms, publicly observable anxiety reactions, and
beliefs about cognitive dyscontrol [26]. Severities of depressive and anx-
ious symptoms were measured with the Brazilian Portuguese versions
of the Beck Depression and Anxiety Inventories (BDI and BAI, respec-
tively) [27]. Whereas the BDI generated low self-esteem, cognitive-
affective and somatic subscores [28]; BAI total scores were decomposed
into neurophysiologic, subjective, panic and autonomic subscores [29].
Each of the scales subscores of all scales was split into 3 levels of se-
verity (mild, moderate and severe) through K-means clusterization
method to obtain minimal variance within each interval of the re-
sponses. For example, the first subscore of ASI-36 (fear of cardiovascular
symptoms) was divided into mild, moderate and severe levels, corre-
sponding to scores ranging from 0 to 4; 5 to 13; and 14 to 24 values, re-
spectively. This strategy generated an additional 76 variables for our
analysis (see Fig. 1 and Table 2) other than the diagnostic groups them-
selves (OCD, SAD and PD). K-means clusterization was performed by
the software “R” (version 3.5.1).
2.3. Statistical analysis
For the analysis of differences between groups in terms of
sociodemographic and clinical variables, we computed chi-square
tests for dichotomous variables and analyses of variance for continuous
variables. If MANOVAs indicated significant group effects, post-hoc con-
trasts were computed using Tukey's test. The level of statistical signifi-
cance was 0.05. For these analyses, we used IBM SPSS Statistics
Version 25.0 for Mac [30].
Our decision to work with symptom domains as qualitative ordinal
variables lead to the choice of performing a multiple correspondence
analysis (MCA) using the three diagnostic groups and the variables cre-
ated from the severity of symptoms as explained above. The choice of
this method allows all variables to be analysed simultaneously without
the diagnostic restraints required by a bivariate analysis.
Missing values of severity of symptoms were replaced by multiple
imputation through the regularized iterative MCA algorithm. The latter
strategy guarantees an adequate treatment of the data even with non-
random losses below 30%, which would be higher than what occurred
in our sample (below than 10%) [31]. Both analyses were also per-
formed by the software “R” (version 3.5.1) [32].
3. Results
The socio demographic and clinical characteristics of the sample are
summarized in Table 1. They are similar to previous studies using
3
partially overlapping subjects [33–35]. Importantly, the three groups
did not differ in terms of sex (χ2 = 1.57, df = 2, p = .45), age
(Kruskal-Wallis H = 2.145; df = 2; p = .34), marital status (χ2 =
8.05, df = 8, p = .43), professional degree (χ2 = 6.22, df = 8, p =
.62), and comorbidity with current major depressive disorder (χ2 =
0.40, df = 2, p = .82). A comparison between the groups in terms of
other clinical variables (e.g. including age at symptoms' onset, duration
of illness, illness perception, and duration of untreated illness) has been
published elsewhere [33,34].
The MCA was performed with 79 variables, including 76 severity of
symptoms (divided into mild, moderate and severe) and three diagnos-
tic groups (OCD, SAD, and PD). The MCA generated five dimensional as-
sociations between the variables that can be represented in a
bidimensional graphic. In our particular case, the combination of the
graphical representation of the first and second dimensions (see Fig.
2) explained better our model (30.5%). Its corresponding numerical rep-
resentation can be visualized in Table 2.
All variables representing the mildest symptoms were grouped
without correlating with any particular diagnostic group. Moderate
symptoms, however, were more dispersed than milder symptoms,
and formed two groups. A first one (termed the moderate uncompli-
cated “neurotic” group) involved all SPIN, BDI, and DOCS subscores;
subscores 1 and 2 of BAI (neurophysiologic and subjective anxieties);
subscores 1, 2 and 3 of the PAS (panic attacks, agoraphobic and anticipa-
tory anxiety); and subscore 4 of the ASI (fear of publicly observable anx-
iety reactions). This first moderate group did not map into any of the
three diagnostic categories.
In contrast, a second group (termed moderate complicated “neu-
rotic” group) mapped more clearly into PD rather than on OCD or
SAD. It included moderate symptoms of subscores 4 and 5 of PAS (dis-
ability and worries about health); subscore 4 of BAI (autonomic anxi-
ety); and all subscores of ASI with the exception of ASI 4 (including
fear of cardiovascular, respiratory, gastric, neurologic and cognitive
dyscontrol symptoms). The only moderate symptom variable that did
not clearly map into these two groups was subscore 3 of BAI (panic),
which also did not map into any specific diagnostic category.
Finally, all symptom domains of higher severity (here described as
the severe dispersed “neurotic” symptom domains.) did not produce a
well-defined homogeneous cluster as noted in the previous two groups.
Curiously, they also tended to distance themselves from the three diag-
nostic categories. Apparently, as severity of OCD and anxiety disorders
symptoms increase, they tend to stand as prominent isolated clinical
phenomena.
4. Discussion
As research on psychiatric nosology progresses, the validity of DSM
diagnostic entities, either as “discrete” categorical conditions and/or as
phenotypically homogeneous disorders, are being increasingly chal-
lenged. In the present study, we found evidence supporting a predomi-
nantly dimensional approach to OCD and anxiety disorders. As
predicted, OCD, SAD, and PD symptom domains did not map exactly
into their corresponding diagnostic categories but tended to lie within
a single spectrum of severity, with milder symptom domains being
more likely to cluster together. In particular, symptom domains and dis-
orders were grouped into [1] a single mild “neurotic” syndrome charac-
terized by multiple, closely related and milder co-occuring symptom
domains; [2] two moderate (complicated and uncomplicated) “neu-
rotic” syndromes (associated or not with panic disorder, respectively);
and [3] severe but dispersed “neurotic” symptom domains.
Our findings supporting the existence of a single spectrum of sever-
ity involving all relevant OCD and anxiety disorders symptom domains
are consistent with the concept of “general neurotic syndrome” initially
proposed by Tyrer et al. as a combination of anxiety and depressive
symptoms associated with anxious, dependent and obsessional person-
ality traits, often interspersed with episodes of social anxiety, panic and
4 P. Vigne et al. / Comprehensive Psychiatry 94 (2019) 152116

Table 1
Clinical and sociodemographic characteristics of participants.

Variables OCD SAD (N = 34) PD Statistic and p-value

(N = 38) (N = 36)

Female (%) 18 (47.4%) 15 (44.1%) 21 (58.3%) X2 = 1.576, df = 2, p = .455

Age (SD) 39.37 (12.716) 42.00 (14.643) 43,89 (11.971) Kruskal-Wallis H = 2.145; df = 2; p = .34,
Marital status (%) X2 = 8.054, df = 8, p = .428
Single 60.5% 58.8% 41.7%
Married 31.6% 29.4% 30.6%
Separated/divorced 5.3% 8.8% 19.4%
Other 2.6% 2.9% 8.4%
Professional degree (%) X2 = 6.222, df = 8, p = .622
No degree 15.8% 5.8% 22.2%
Non-University degree 44.7% 52.9% 38.9%
University degree 28.9% 32.4% 27.8%
Other 10.5% 8.8% 11.1%
Comorbid MDD (current) 28.1% 31.3% 315% X2 = 0.40, df = 2, p = .819
Cross-comorbidity between OCD, SAD, and PD (current)
OCD 65.6% 3.1% 10.7% X2 = 37.1, df = 2, p b .001
SAD 18.8% 71.9% 0.0% X2 = 39.4, df = 2, p b .001
PD 6.3% 6.3% 46.4% X2 = 20.8, df = 2, p b .001

Footnote: OCD = obsessive-compulsive disorder; SAD = social anxiety disorder; PD = panic disorder; MDD = major depressive disorders.

somatoform symptoms [36]. It also matches the observation that a sub-
stantial number of subjects fall short of meeting diagnostic criteria for
OCD [37] or other anxiety disorders [38,39], either because of the adop-
tion of non-tested and arbitrary cut-off criteria (such as the presence of
distress or impaired functioning) when they still experience substantial
impairments in health, psychological vulnerability and psychiatric co-
morbidity [40] or because of descriptions of certain symptoms as
being fundamental for diagnosis (e.g. obsessions and/or compulsions
in OCD), at the expense of other, less commonly reported, but equally
relevant diagnostic features (e.g. obsessional slowness [41] or sensory
phenomena in OCD [42]).
The finding of a single mild “neurotic” syndrome characterized by
multiple and closely related symptom domains might be consistent
with the idea of an early prodromal shared pathway for OCD, SAD,
and PD. This syndrome might have some overlap with traits such as in-
creased neuroticism [43] in the absence of clinically significant symp-
toms or even with the so called “Clinical High At Risk Mental State”
[20], where a common “pluripotent” state can differentiate itself in a
number of “exit” syndromes. Alternatively, the existence of a milder
cluster may reflect the fact that all anxiety disorders (and to a lesser ex-
tent OCD [44]) share similar response profiles, often to the same treat-
ment strategies (serotonin reuptake inhibitors and exposure therapy)

Fig. 2. Multiple correspondence analysis map of diagnostics groups and severity of symptoms (projections on the first 2 dimensions). Footnote: OCD = Obsessive-Compulsive Disorder; PD
= Panic Disorder; SAD = Social Anxiety Disorder. Scales: ASI = Anxiety Sensitivity Index; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; DOCS = Dimensional
Obsessive-Compulsive Scale; SPIN = Social Phobia Inventory; PAS = Panic and Agoraphobia Scale. Each item in red describes a specific symptom, i.e. the scale in question, the number
of the subscore of the scale, and the severity of the specific subscore (mild = mild; mod = moderate; sev. = severe). Symptoms subscore of each scale: BDI1 = Low self-steem; BDI2
= Cognitive-afffective; BDI3 = Somatic; BAI1 = Neurophysiologic; BAI2 = Subjective; BAI3 = Panic; BAI4 = Autonomic; DOCS1 = Contamination; DOCS2 = Harm; DOCS3 =
Thoughts; DOCS4 = Symmetry; SPIN1 = Fear; SPIN2 = Avoidance; SPIN3 = Physiologic arousal; ASI1 = Cardiovascular; ASI2 = Respiratory; ASI3 = Gastric; ASI4 = Fear of publicly
observable anxiety reactions; ASI5 = Neurologic; ASI6 = Cognitive Dyscontrol; PAS1 = Panic Attacks; PAS2 = Agoraphobic; PAS3 = Antecipatory anxiety; PAS4 = Disability; PAS5
= Worries about health.
 P. Vigne et al. / Comprehensive Psychiatry 94 (2019) 152116 5

Table 2
The contribution of variables (each subscore split into 3 levels of severity)to the definition of the two first dimensions from multiple correspondence analysis.

BDI1 BDI2 BDI3 BAI1 BAI2 BAI3 BAI4

(Low self-esteem) (Cognitive-affective) (Somatic) (Neurophysiologic) (Subjective) (Panic) (Autonomic)

Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev

Dimension 1 0.99 0.23 2.44 1.84 0.26 2.44 1.33 0.51 2.29 1.61 0.31 3.11 2.01 0.01 3.57 1.71 1.23 1.59 1.36 0.45 2.90
Dimension 2 0.13 1.51 2.03 0.75 2.50 0.67 0.51 2.68 1.76 0.34 2.12 1.00 0.87 2.01 0.10 0.34 0.25 0.30 0.47 4.25 1.96

DOCS1 DOCS2 DOCS3 DOCS4 SPIN1 SPIN2 SPIN3

(Contamination) (Harm) (Thoughts) (Simmetry) (Fear) (Avoidance) (Physiologic
arousal)

Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev

Dimension 1 0.28 0.06 1.68 0.59 0.04 1.58 0.80 0.14 2.05 0.44 0.03 1.69 0.93 0.06 1.10 1.02 0.03 1.75 1.45 0.05 2.34
Dimension 2 0.18 0.19 1.97 0.01 0.24 0.54 0.30 1.25 0.63 0.00 0.51 1.71 0.09 0.98 0.62 0.01 0.53 0.76 0.28 2.08 1.03

ASI1 ASI2 ASI3 ASI4 ASI5 ASI6

(Cardiovascular) (Respiratory) (Gastric) (Fear of publicly (Neurologic) (Cognitive
observable anxiety Dyscontrol)
reactions)

Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev

Dimension 1 1.73 0.04 2.95 1.92 0.04 3.27 1.26 1.00 2.02 1.37 0.02 2.48 1.88 0.94 2.97 2.01 0.05 3.50
Dimension 2 1.18 5.19 1.41 1.51 6.43 1.80 0.14 4.14 2.75 0.11 1.13 0.67 0.26 4.83 4.62 0.65 4.42 0.58

PAS1 PAS2 PAS3 PAS4 PAS5

(Panic attacks) (Agoraphobic) (Antecipatory anxiety) (Disability) (Worries about health)

Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev Mild Mod Sev

Dimension 1 0.78 0.83 1.40 1.00 0.13 2.57 0.94 0.03 3.34 0.92 0.65 2.25 1.52 0.76 2.70
Dimension 2 0.42 1.33 0.08 1.39 1.02 0.24 1.34 2.24 0.03 0.55 2.03 0.04 0.24 2.45 1.74

Footnote: ASI = Anxiety Sensitivity Index; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; DOCS = Dimensional Obsessive-Compulsive Scale; SPIN = Social Phobia
Inventory; PAS = Panic and Agoraphobia Scale. Each subscore was split into 3 levels of severity (mild = mild; mod = moderate; sev = severe).

[45], which may lead to common “residual” states. In contrast, the mod-
erate “complicated” group, which was associated with PD (and as such,
with increased disability), is the reflection of a spectrum of severity of
symptom domains, where the detachment of each other reaches its
maximum expression in the “severe” group.
It could be argued that its small sample size and focus on treatment
seeking subjects in different stages of treatment are significant limita-
tions of this study. However, a number of additional factors need to be
similarly considered. Firstly, MCA is sufficiently robust to be employed
in low numbers. Secondly, treatment seeking samples might be partic-
ularly interesting for studies on the relationship between comorbid dis-
orders, which seem to be over represented in clinical settings. Finally,
although it is tempting to speculate on the existence of a common path-
way whereby subjects are firstly affected by common mild neurotic
symptoms to then develop later independent and more specific yet in-
dependent symptom domains, the cross sectional design of our study
does not allow us to make such extrapolation. Future longitudinal stud-
ies would be interesting to clarify this important point.
Financial support
This work was supported by the Conselho Nacional de
Desenvolvimento Científico e Tecnológico (L.F., grant number 308237/
2014-5), Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro,
(L.F., grant number 203590); the D'Or Institute of Research and Educa-
tion (L.F., no grant number available); and the David Winston Turner
Endowment Fund (L.F., no grant numbers available).
Role of the funding source
The funding sources had no role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in
the decision to submit the article for publication.
Declarations of competing interest
None.
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